Evaluation of proton pump inhibitor administration in hospitalized dogs in a tertiary referral hospital

Abstract Background Although proton pump inhibitors (PPIs) are commonly administered to hospitalized dogs, prescribing patterns and appropriateness of use require continued investigation. Hypothesis/Objective Describe prescription patterns and appropriateness of use associated with PPIs in hospitalized dogs at a single tertiary care facility. We hypothesized that the majority of prescriptions would not comply with current guidelines for the rational use of acid suppressants. Animals Two hundred randomly selected hospitalized dogs. Methods Retrospective evaluation of the medical records associated with a randomly selected sample of hospitalized dogs that received PPIs between January 2013 and December 2018. Results A total of 12 610 dogs were admitted for first‐time hospitalization between January 2013 and December 2018. Forty percent of these dogs (5062/12610) were prescribed a PPI PO or IV. Of the 200 randomly selected records, an adequate indication for use was identified in 27% of dogs (54/200). Of the dogs surviving to discharge, 54% (95/175) were discharged with a PPI and 51.6% (49/95) of those were prescribed an inadequate dose. Conclusions and Importance Our findings support other studies in which the majority of PPI prescriptions for hospitalized dogs at a tertiary care hospital lacked an appropriate indication. Furthermore, analysis of the prescribing patterns of dispensed PPIs identified a frequent occurrence of dosages considered inadequate, raising concern for ineffective treatment even with appropriate indications of use. With growing concern of adverse effects associated with PPI and other acid suppressant administration in human and veterinary medicine, rational use of these medications following consensus guidelines should be emphasized and treatment should be reserved for dogs with historical, physical examination, clinicopathologic, and imaging findings supportive of an appropriate indication for use.

Results: A total of 12 610 dogs were admitted for first-time hospitalization between January 2013 and December 2018. Forty percent of these dogs (5062/12610) were prescribed a PPI PO or IV. Of the 200 randomly selected records, an adequate indication for use was identified in 27% of dogs (54/200). Of the dogs surviving to discharge, 54% (95/175) were discharged with a PPI and 51.6% (49/95) of those were prescribed an inadequate dose.
Conclusions and Importance: Our findings support other studies in which the majority of PPI prescriptions for hospitalized dogs at a tertiary care hospital lacked an appropriate indication. Furthermore, analysis of the prescribing patterns of dispensed PPIs identified a frequent occurrence of dosages considered inadequate, raising concern for ineffective treatment even with appropriate indications of use. With growing concern of adverse effects associated with PPI and other acid suppressant administration in human and veterinary medicine, rational use of these medications following consensus guidelines should be emphasized and treatment should be reserved for dogs with historical, physical examination, Use of PPIs without clear indications despite increased risk for adverse effects also is considered common in veterinary medicine as determined by other studies. [5][6][7][8] Our objective was to describe the prescription patterns and appropriateness of PPI administration in hospitalized dogs at a single tertiary care facility.
We hypothesized that the majority of prescriptions would not comply with current guidelines regarding appropriate indication of PPI use. 9 2 | MATERIALS AND METHODS were sorted chronologically based on date of admission. The first and tenth dogs were selected and then every 50th record was reviewed.

| Study design and overview
The following data were collected: (a) signalment, (b) admitting service, (c) PPI administered, (d) primary diagnosis identified, (e) concurrent disease, (f) survival to discharge, (g) outpatient prescription of PPIs, (h) concurrently prescribed medications, (i) dose of outpatient prescription, (j) instructions for outpatient use, and (k) directions for discontinuation.   Table 1.  Table 2.     3 and it is possible that this number is underestimated

| DISCUSSION
given that PPIs are available over the counter. Furthermore, chronic PPI use has been associated with a number of adverse events including acute kidney injury, 10,11 osteoporotic fractures, 12 hypocobalaminemia, 13 hypomagnesemia, 14 and dementia. 15 Several studies describe the frequency and type of adverse effects associated with PPI administration in dogs. 5,6,8 Despite these studies, inappropriate use of these medications is as likely or more common than observed in human medicine. For example, in a recent survey of small animal general practitioners in Portugal, 98.3% had prescribed a PPI without an appropriate indication for use. 16 Gastric acid secretion is a normal physiologic mechanism that contributes to appropriate digestion of protein, release of cobalamin, absorption of inorganic iron 17 and calcium, 18  The effective dose of omeprazole in dogs to achieve gastric pH goals known to result in healing of upper GI ulceration and erosion in humans has been suggested to be 1.0 mg/kg PO q12h, although recent evidence suggests that 0.5 mg/kg is effective as long as it is administered q12h. 26,27 In our study, 52% of dogs were prescribed an inadequate dose, raising concern for ineffective treatment. It is possible that this percentage at least partially reflects the timeframe from which the records were selected compared to the date with which the ACVIM consensus statement on the rational use of gastro-protectants was published. Last, of the dogs that were discharged with client instructions to continue a PPI PO, 92% of dogs had no directions or inadequate directions for administration and no dogs had directions to taper the medication before discontinuation, which could represent lack of understanding of the pharmacologic properties, affect overall efficacy of treatment, and lead to adverse effects associated with gastric acid hypersecretion after abrupt discontinuation of treatment.
Of those surviving to discharge, 54% of dogs that were administered a PPI in hospital were not discharged with a PPI, which may suggest inappropriate use of this medication given the current standards of The limitations of our study include its retrospective nature. Portions of the dog's history, physical examination findings, and progress in hospital may not have been adequately documented in the written medical record, precluding identification of an adequate indication for use. Furthermore, the percentage of prescriptions without discontinuation instructions could be overestimated given that the prescribing clinician could have intended for the client to discontinue omeprazole once the original number of tablets had been administered.
The evaluation of inpatient prescriptions of PPIs at a tertiary care facility identified that the majority were prescribed with an inappropriate indication for use. Furthermore, hospitalized dogs that received PPIs frequently were not provided a PPI on discharge, raising concern for lack of rational drug use given recommended duration of treatment for suspected gastric-acid related disorders. The prescribing patterns in those dogs that were discharged with PPIs also indicated a high prevalence of inadequate doses to meet criteria for gastric acid suppression. Last, our evaluation identified a high number of concurrently prescribed medications, which may raise concern for an inverse relationship with client compliance with regard to medication administration. An additional study to evaluate whether the ACVIM consensus statement guidelines have since altered practices at our institution would be advisable.

ACKNOWLEDGMENT
No funding was received for this study. This data was presented in part at the 2020 ACVIM Forum On Demand.